Medication management of pain is part of the multidisciplinary
approach to treatment and is designed to enable the patient to resume
normal daily activities. Because the pain persists, extended drug
treatment becomes necessary. Even though several different drugs are
used in managing chronic pain, the effectiveness of most medications
has not been demonstrated by controlled clinical trials. The physician
always considers these issues along with patient-specific factors,
including other medical problems and side effects of medications, and
federal and state regulatory requirements, when selecting the most
appropriate drug treatment for a patient with chronic pain.In a survey
conducted in November of 1998, when asked to rate the effectiveness
of the pain medicine they had tried, chronic pain sufferers gave opioid
(narcotic) drugs, the highest score. Approximately half of the patients
who had taken narcotics reported concerns about addictions – fears
that experts believe are often exaggerated or misplaced. When it comes
to medication management, every chronic pain patient should ask themselves
if they have any fears or concerns about pain medications. Many people
are reluctant to take pain medications because of concerns about side
effects. Others are worried they will become “hooked” or addicted.
Contrary to the patient opinion’s, most physicians consider chronic
administration of narcotics as detrimental to the patient’s health
and also causes addiction. Several medications are available for treating
chronic pain of varying intensity apart from narcotics:
1. Most commonly used drugs are known as non-steroidal
anti-inflammatory drugs (NSAIDS). These are used mainly for
mild to moderate pain. These are available over-the-counter, as
well as with prescription. These include aspirin, Tylenol, ibuprofen,
and numerous other drugs such as Lodine ®, Daypro ®, Celebrex ®,
Vioxx ® and, Bextra ®.
2. The second group of drugs used is narcotics. Generally
narcotics are indicated only for severe pain. There are numerous types
of narcotics available in the market which range from mild drugs such
as Darvocet ®, Darvon and Ultram® to moderately potent drugs such as
Talwin ®, Stadol ®, Hydrocodone (most commonly known as Lortab ®, Lorcet ®,
Vicodin®, etc), and in the high range, the most potent drugs are Oxycodone
(also known as OxyContin ®, Percodan ® , Percocet ® , or Tylox), Demerol,
Morphine, and Methadone.
3. Other drugs used in managing chronic pain
include muscle relaxants, medications used for depression and anxiety,
medications used in convulsions, and medications given into the epidural
space or spinal cord which include steroids and morphine.
4. Tylenol or acetaminophen is useful for
mild pain. However, Tylenol does not have anti-inflammatory activity
whereas others do. It is believed to reduce pain by inhibiting the
generation of peripheral pain impulses and transmission of central
nociceptive impulses. Tylenol is a relatively safe drug because it
causes few side effects. However, it has the potential to cause liver
toxicity, especially in people who consume more than three alcoholic
drinks per day or who have liver dysfunction, or who take more than
six tablets of Tylenol a day.
Non-steroidal anti-inflammatory drugs have pain relieving
effects similar to Tylenol and at the same time, have anti-inflammatory
effects which reduce the inflammation and also reduce the fever. These
drugs work by inhibiting cyclooxygenase (more formally known as Cox
Pathways) by inhibiting the production of prostaglandins. Cox pathways
are further divided into two types: Cox I, which is present in most
tissues and Cox II, which is induced by various substances in the body
including endotoxins, so-called mitogens, and cytokines. The majority
of non-steroidal anti-inflammatory drugs which are currently on the
market and used in the treatment of arthritis or pain, non-selectively
inhibit both Cox I and Cox II. Of course, some of the drugs work more
on Cox II than Cox I.
In 1998 Celebrex ® (a selective Cox II inhibitor)
was introduced, followed in 1999 by Vioxx ® (also a selective Cox II
inhibitor) and Bextra ® in 2001. While Cox II inhibitors may be safer,
the effectiveness either is equal or better. Non-steroidal anti-inflammatory
agents are the most frequently prescribed medications for chronic pain. Low
doses, such as Ibuprofen 400 mg, three times a day, provide pain relief,
whereas higher doses, such as Ibuprofen 800 mg, three times a day,
are needed for full anti-inflammatory action. However, it is not known
whether there is any type of inflammation present in chronic pain at
all. In general, evidence shows that these agents work better than
sugar pills.
Because prostaglandins work to maintain gastrointestinal
tract integrity, normal kidney blood flow, and balance among various
substances in the body, non-steroidal anti-inflammatory drugs have
the potential to cause important adverse events, especially among the
elderly. NSAIDS cause significant gastrointestinal effects with stomach
upset and occasional ulceration, along with damage to the kidney and
kidney failure, especially in patients with compromised kidney function. They
may also cause liver disease, and occasionally cause sodium and fluid
retention, especially in patients with heart failure. NSAIDS may also
result in increase blood pressure in patients with coronary artery
disease, and, finally, they may cause increased levels of potassium
in diabetic patients.
Ultram® is a mixed agent functioning centrally on
the brain cells, which is effective in the management of moderate to
severe pain. It has been shown in studies to be equivalent to the
effects produced by Tylenol #3. It presents with two types of actions,
one is a narcotic type of action and the other one is similar to antidepressant
medications. Even though it is considered to have a low potential
for abuse or dependence, it is not advised to be used in patients with
a history of abuse or drug dependence.
Pure narcotic agents produce pain relief by binding
to opioid receptors at spinal and supraspinal sites. Narcotic analgesics
mainly are used to treat severe pain. Their duration of action ranges
from three to six hours with Codeine or Oxycodone, to three days with
long-acting drugs like Fentanyl patches. Many physicians are reluctant
to recommend extended use of narcotic medications for chronic non-cancer
pain due to the safety and addiction potential. Various types of narcotic
agents include Codeine (Tylenol #2, #3, and #4), Percodan ®, Percocet ®,
Tylox ®, OxyContin ®, Oxycodone, Morphine, Hydromorphone (Dilaudid®),
Propoxyphene (Darvocet® or Darvon®), Hydrocodone (Lortab ®, Lorcet ®,
Zydone ®, Vicoprofen ®, and Vicodin®) and Fentanyl (Duragesic ® patches).
Muscle relaxants have a limited role in the treatment
of chronic pain because muscle spasm is unlikely to be the source of
chronic pain even though numerous patients complain of this. In addition,
these drugs produce undesirable side effects which include drowsiness
with long-term use. In addition, they have not been shown to be effective
in chronic pain management in various studies.
Antidepressants are useful in patients with chronic
pain with or without clinical depression. In patients with depression,
higher doses are used to counteract depression and also help pain. However,
antidepressants have been shown to be helpful in managing chronic pain,
especially pain coming from damage to the nerve endings.
Anticonvulsants or medications used in epilepsy and
seizures are also useful in chronic pain management, especially with
nerve injury or damage.
Medication management is an extremely important aspect
of pain management. Medication management of chronic pain always poses
a challenge to primary care physicians. In selective pain medications,
the physician must consider the intensity and duration of chronic pain,
as well as a number of other factors, including patients age, other
medical problems, other medications, and serious side effects, as well
as potential for drug abuse. Regardless of any type of management,
medication should be part of the multidisciplinary approach that should
include medication management in conjunction with other treatments. The
Federation of State Medical Boards of the United States, Inc has developed
model guidelines for the use of controlled substances for the treatment
of pain. These guidelines were developed from a working group, which
included members of the American Academy of Pain Medicine, American
Pain Society, American Society of Law, Medicine, and Ethics, Pain and
Policy Studies Group, University of Wisconsin, and various State Boards. These
are only model guidelines and have not been implemented by all State
Medical Boards. Salient features of these guidelines are:
1. Comprehensive evaluation of the patient
2. Written treatment plan
3. Informed consent and agreement for treatment including
controlled substances agreement
4. Periodic review
5. Appropriate consultations as necessary
6. Maintain medical records
7. Compliance with controlled substances loss and regulation